In a lonely place

Shrouded in myth and taboo, male sexual assault is under-reported and poorly researched. This month, the law in England and Wales is set to change to improve conditions for men who have been raped. Catherine Armitage explains the new law and takes a look at the medical, social, and psychological impact of male sexual assault

Sexual assault of men is often not reported and, as a consequence, poorly understood, but awareness that this crime is a worldwide problem is increasing. For example, in the past, male rape was not recognised as a criminal offence in England and Wales, and in 1995 only did changes in the law mean it became a recognised crime. Before this, no statistics had been collected on male sexual assault. In 1995, police recorded 150 cases nationally making male rape 2.9% of all rapes reported. This number rose to 735 (7.5%) of all rapes recorded in 2001-2.¹ But police figures do not reflect the true prevalence of sexual assault on men--the crime is under-reported.

However, the law in England and Wales is changing. The Sexual Offences Bill received royal assent in November 2003 and may become law as early as this May. This is the most radical overhaul of legislation in relation to sex crimes in England and Wales for 50 years. It includes guidelines on the issue of consent with regards to rape and cites equality in the law for men and women.

Another problem in understanding males sexual assault it that there is little collected data from other sources. But what there is suggests that the problem is more prevalent than police figures show. A general practice based study done in 1991 found that almost 3% of men reported non-consensual sexual experiences as adults.² In the United States, a sample of 1480 men revealed that 7% of them felt "pressured or forced to have sexual contact."³ A more recent Australian study questioned 10 173 men on many aspects of their sexual health and relationships. It found that 4.8% of men experienced sexual coercion, with 2.8% disclosing that this occurred under the age of 16.⁴ And testimonies from countries besieged by war show that both men and women are subjected to rape at times of civil unrest.

Why are sexual crimes against men under-reported? Many myths and taboos exist about sexual assault on men and low reporting rates help to perpetuate the myths associated with sexual assault. Some people believe that men cannot be raped--they are assertive sexually, enjoy all sexual encounters, and are strong enough to defend themselves against anything. Men are seen as responsible for the crime and not the victim. Another commonly held perception is that a man who is sexually assaulted by another man must be gay whereas in reality, rape is not about sexual attraction but power and control. Not knowing where to turn to and fearing a hostile response discourage men from disclosing that they have been raped.

Contrary to such myths, there is no typical profile of a man subjected to rape--but there are factors that identify both men and women at risk of sexual violence. Young age, poor educational level, and past history of sexual assault all make someone more vulnerable to sexual assault. Sex work and residence in prison are also associated factors, but little data exists on sexual assault in these groups of men.

There are also few data on the sexual orientation of men that are raped. However, one study showed that most men who reported non-consensual sex with other men defined themselves as primarily heterosexual.²

Neither is there a typical profile of an assailant, but most men who do say that they have been assaulted report that they were assaulted by other men. It is less common for a woman to assault a man or to help a male assailant. Because of the small number of men reporting the crime, there is little information on whether male rape is done by strangers or someone known to the complainant.

Consequences for health care

Many sexual assaults will go unreported to the police but the survivors of these sexual assaults will often tell a doctor. General practitioners, doctors working in emergency departments, and genitourinary doctors are most likely to encounter men who have been sexually assaulted. Emergency departments tend to deal with injuries and arrange inpatient care if needed, and sexual health services offer confidential advice and screening for sexually transmitted infections.

If a man is sexually assaulted there are both physical and psychological considerations. As a medic, you may need to examine him physically. Oral, anal, penile, or bodily injuries may result after a sexual assault. Many people presume that all assaults result in injuries and that the absence of injuries may be used to question the veracity of an allegation. However, the results of a study at the sexual assault referral centre at St Mary's Hospital in Manchester, United Kingdom, showed that anal rape in males resulted in an injury in just a quarter of cases.

All sites exposed during the assault should be tested for gonorrhoea and chlamydia. This may involve urethral, anal-rectal, and pharyngeal swabs. Chlamydia culture is recognised in a court of law in England and Wales but has poor sensitivity. Testing for chlamydia with nucleic acid amplification techniques is more sensitive so both this and culture are recommended. In addition to cultures, Gram stains for gonorrhoea from the urethra and rectum can be done quickly in genitourinary clinics and give a result the same day. Blood testing for syphilis should include the fluorescent treponemal antibody test as this is the first test that becomes positive in early syphilis.

CLAY PATRICK/PHOTONICA

Myth and stigma may prevent
a man from reporting a sexual assault

Forced anal penetration has a greater risk than penile-vaginal rape with an HIV infected assailant. Postexposure prophylaxis for HIV is controversial--it may be considered, but no guidelines currently exist in the United Kingdom for non-occupational exposure to HIV and different services for provision of the prophylaxis exist in different healthcare settings. However, doctors involved should assess the risk for every case and discuss the relevant risks with the patient to allow them to have an informed choice--but risk assessment is difficult when the assailant is a stranger and the patients' decision to test for HIV may be affected by the amount of time that has passed since the assault. Local HIV services, an infectious diseases team, or the virologist on call may provide advice and access to antiretroviral treatment, or the drugs may be stored in the emergency department. At this stage, doctors may want to consider testing for hepatitis B and hepatitis C and provide a vaccination against hepatitis B.

Doctors should also offer counselling and psychosocial support and refer the patient to psychological and other support agencies. The British Association for Sexual Health and HIV have produced guidelines on the management of adults disclosing sexual assault in a genitourinary setting and can be accessed through their website.⁵

Psychological impact of sexual assault

Men will experience similar feelings to women after an assault such as shame, self blame, and guilt. However, men may have extra issues to deal with because of the commonly held belief that men should be able to protect themselves. The resulting isolation and suppression of emotion may manifest in many ways. Depression, anxiety, social alienation, and sexual dysfunction can all result. Antisocial behaviour such as aggression and domestic violence has also been described after an assault. One study described that self harming behaviour--including drug and alcohol misuse--was associated with all forms of sexual molestation.⁶ Some men experience erection or ejaculation during sexual assault. This may lead people to think that rape did not occur. Sexual arousal does not mean that permission was granted. The social consequences and impact of the assault on relationships and employment cannot be ignored.

The way forward: sexual assault referral centres

Traditionally in the United Kingdom, forensic examination and DNA testing has only been accessible once the crime has been reported to the police. The development of sexual assault referral centres has led to provision of the option for "self referral" for forensic examination. This process allows the collection of DNA and intelligence information without initial police involvement. Blood and urine can be sent for toxicology analysis and will help to identify drug facilitated sexual assault. The self referral option may encourage men who have been assaulted to come forward and has helped to identify serial assailants by pooling intelligence. Sexual assault referral centres do not currently cover the whole of the United Kingdom but could be consulted for advice irrespective of the location of the caller.

1. National Statistics for Rape www.met.police.uk/sapphire Accessed 02/03/04
2. Coxell A, King M, Mezey G, Gordon D. Lifetime prevalence, characteristics and associated problems of non-consensual sex in men: cross sectional survey. BMJ 1999;318:846-50.
3. Sorenson SB, Stein JA, Siegel, JM, Golding JM, Burnham MA. The prevalence of adult sexual assault: the Los Angeles epidemiological catchment area project. Am J Epidemiol 1987;126:1154-64.
4. De Visser RO, Smith AM, Rissel CE, Richters J, Grulich AE. Sex in Australia: experiences of sexual coercion among a representative sample of adults. Aust N Z J Public Health 2003;27:198-203.
5. Lacey H. 2001 National guidelines for the management of adult victims of sexual assault. London: British Association for Health and HIV, 2001. www.bashh.org/guidelines/sexassault%2006%2001.pdf (accessed 8 Apr 2004).
6. King M, Coxell A, Mezey G. Sexual molestation of males: association with psychological disturbance. Br J Psychiatry 2002;181:153-7.